There is growing debate about the situations of children who care for a relative with HIV-related illness, especially in developing countries with high HIV prevalence. In particular, there is inadequate information on the long-term consequences of children taking on this caregiving role. The article reanalyses data collected between January and November 2006 in a rural setting in western Kenya where 19 children caring for a total of 15 people living with HIV or AIDS (PLHIV) participated. Data were collected through in-depth interviews, participant observation, focus group discussions and narratives. The findings show that children regularly become involved in caregiving due to lack of a responsible adult to perform the role, which may be as a result of HIV stigma and rejection of the care recipient by extended family members and neighbours or because of cultural barriers. Fulfilling the responsibilities of caregiving had profound repercussions for the children’s lives, including psychological distress, physical burden, dropping out of school, participation in wage labour, and forced early marriage. Financial needs pushed some girls into transactional sexual relations, predisposing them to the risks of unwanted pregnancy or sexually transmitted infections. Since the children providing care for PLHIV are themselves vulnerable, we recommend that they should be targeted with support.

Obstetric fistula is a complication of pregnancy that affects women following prolonged obstructed labour. Although there have been achievements in the surgical treatment of obstetric fistula, the long-term emotional, psychological, social and economic experiences of women after surgical repair have received less attention. This paper documents the challenges faced by women following corrective surgery and discusses their needs within the broader context of women's health. We interviewed a small sample of women in West Pokot, Kenya, during a two-month period in 2010, including eight in-depth interviews with fistula survivors and two focus group discussions, one each with fistula survivors and community members. The women reported continuing problems following corrective surgery, including separation and divorce, infertility, stigma, isolation, shame, reduced sense of worth, psychological trauma, misperceptions of others, and unemployment. Programmes focusing on the needs of the women should address their social, economic and psychological needs, and include their husbands, families and the community at large as key actors. Nonetheless, a weak health system, poor infrastructure, lack of focus, few resources and weak political emphasis on women's reproductive health do not currently offer enough support for an already disempowered group.

Background: Counselling is considered a prerequisite for the proper handling of testing and for ensuring effective HIV preventive efforts. HIV testing services have recently been scaled up substantially with a particular focus on provider-initiated models. Increasing HIV test rates have been attributed to the rapid scale-up of the providerinitiated testing model, but there is limited documentation of experiences with this new service model. The aim of this study was to determine the use of different types of HIV testing services and to investigate perceptions and experiences of these services with a particular emphasis on the provider initiated testing in three selected districts in Kenya, Tanzania, and, Zambia.

Methods: A concurrent triangulation mixed methods design was applied using quantitative and qualitative approaches. A population-based survey was conducted among adults in the three study districts, and qualitative data were obtained from 34 focus group discussions and 18 in-depth interviews. The data originates from the ongoing EU funded research project “REsponse to ACountable Priority Setting for Trust in Health Systems” (REACT) implemented in the three countries which has a research component linked to HIV and testing, and from an additional study focusing on HIV testing, counselling perceptions and experiences in Kenya.

Results: Proportions of the population formerly tested for HIV differed sharply between the study districts and particularly among women (54% Malindi, 34% Kapiri Mposhi and 27% Mbarali) (p < 0.001). Women were much more likely to be tested than men in the districts that had scaled-up programmes for preventing mother to child transmission of HIV (PMTCT). Only minor gender differences appeared for voluntary counselling and testing. In places where, the provider-initiated model in PMTCT programmes had been rolled out extensively testing was accompanied by very limited pre- and post-test counselling and by a related neglect of preventative measures. Informants expressed frustration related to their experienced inability to ‘opt-out’ or decline from the providerinitiated HIV testing services.

Conclusion: Counselling emerged as a highly valued process during HIV testing. However, counselling efforts were limited in the implementation of the provider-initiated opt-out HIV testing model. The approach was moreover not perceived as voluntary. This raises serious ethical concerns and implies missed preventive opportunities inherent in the counselling concept. Moreover, implementation of the new testing approach seem to add a burden to
pregnant women as disproportionate numbers of women get to know their HIV status, reveal their HIV status to their spouse and recruit their spouses to go for a test. We argue that there is an urgent need to reconsider the manner in which the provider initiated HIV testing model is implemented in order to protect the client’s autonomy and to maximise access to HIV prevention.

Obstetric fistula, a devastating maternal health complication associated with social stigma and isolation, is often found in resource-poor settings where access to specialized care is constrained. In this study, the authors examine the perspectives of the healthcare providers on the factors that contribute to obstetric fistulae formation in West Pokot, Kenya. Key informant interviews with healthcare providers, social workers and traditional birth attendants were held to generate information on factors contributing to formation of obstetric fistulae. Thematic analysis based on grounded theory approach was used. Factors that contribute to the occurrence of obstetric fistulae include: female genital mutilation and early forced marriage; unskilled birth attendants and associated birth rituals; infrastructural constraints; and lack of women's empowerment. There is interplay between sociocultural, structural and economic forces in the region that culminate in maternal morbidity and possible mortality. Healthcare providers' perspectives are vital in understanding maternal health problems in rural Kenya. Community level initiatives aimed at improving the health of women in rural resource-poor areas should be encouraged.

Ecological factors have contributed to increased malaria transmission in sub-Sahara Africa. This study was designed to document perceived and actual ecological changes in Gusii over the last three decades; to document changes in the malaria burden and to collect ethnographic data to understand folk causal linkages between environmental change and disease patterns. Over a 12-month period data was collection using malaria focused-ethnographic interviews, historical narratives and a review of statistical health records. A total of 103 people were interviewed. Historical narratives reveal a decline in landholdings over three decades. Hospital health records show that over this period, the burden of malaria has increased. Ethnographic interviews and hospital records show that the period during which malaria is most intense is between May and August, with July as the peak period. Ethnographic data point to weather changes, changes in landholdings and land use as the primary factors in the observed changes in the malaria patterns in Gusii. In conclusion, in the absence of documented data folk knowledge is a useful substitute for constructing trends.

Objectives: This paper examines trends and underlying causes of attrition among volunteer community health workers in home-based care for people living with HIV and AIDS in western Kenya. Methods: Ethnographic data were collected between January and November 2006 through participant observation, focus group discussions and in-depth interviews with 30 CHWs, NGO staff and health care providers and 70 PLWHA. Results: An attrition rate of 33% was observed among the CHWs. The reasons for dropout included: the cultural environment within which CHWs operated; lack of adequate support from area NGOs; poor selection criteria for CHWs; and power differences between NGO officials and CHWs which fostered lack of transparency in the NGOs’ operations. Conclusions: In order to achieve well-functioning and sustainable HBC services, factors which influence retention/dropout of CHWs should be addressed taking into account the socio-cultural, programmatic and economic contexts within which CHW activities are implemented.

Although early diagnosis and treatment are key factors in the effective control of human African trypanosomiasis (HAT), many cases of the disease delay taking appropriate action, leading to untold suffering. As a better understanding of treatment-seeking behaviour should help in identifying the obstacles to early diagnosis and effective treatment, the treatment pathways followed by 203 former HAT cases in western Kenya and eastern Uganda have recently been explored. About 86% of the HAT cases had utilized more than two different healthcare options before being correctly diagnosed for HAT, with about 70% each using more than three different health facilities. Only about 8% of the cases reported that they had been correctly diagnosed the first time they sought treatment. Just over half (51%) of the HAT cases had been symptomatic for >2 months before being correctly diagnosed for HAT, and such time lags in diagnosis contributed to 72% of the cases receiving their first appropriate treatment only in the late stage of the disease. The likelihood of a correct diagnosis increased with the time the case had been symptomatic. These observations indicate an urgent need to build the diagnostic capacity of the primary healthcare facilities in the study area, so that all HAT cases can be identified and treated in the early stage of the disease.

SETTING: The Abagusii people in rural south-west Kenya. OBJECTIVE: To investigate tuberculosis (TB) treatment pathways and factors associated with treatment-seeking behaviour. METHOD: Quantitative data were obtained using a structured questionnaire administered to 100 household heads, while qualitative data were obtained from three focus group discussions (FGDs), six key informant interviews and seven case histories that focused on experiences of TB. RESULTS: Data reveal that patients follow oscillatory pathways in treatment seeking. Treatment-seeking behaviour is influenced by socio-structural and superstructural forces such as beliefs and perceptions regarding treatment and disease-causing factors. CONCLUSION: To improve TB treatment, these socio-structural and superstructural factors should be addressed.

Despite multiple efforts to strengthen health systems in low and middle income countries, intended sustainable improvements in health outcomes have not been shown. To date most priority setting initiatives in health systems have mainly focused on technical approaches involving information derived from burden of disease statistics, cost effectiveness analysis, and published clinical trials. However, priority setting involves value-laden choices and these technical approaches do not equip decision-makers to address a broader range of relevant values - such as trust, equity, accountability and fairness - that are of concern to other partners and, not least, the populations concerned. A new focus for priority setting is needed. Accountability for Reasonableness (AFR) is an explicit ethical framework for legitimate and fair priority setting that provides guidance for decision-makers who must identify and consider the full range of relevant values. AFR consists of four conditions: i) relevance to the local setting, decided by agreed criteria; ii) publicizing priority-setting decisions and the reasons behind them; iii) the establishment of revisions/appeal mechanisms for challenging and revising decisions; iv) the provision of leadership to ensure that the first three conditions are met. REACT - "REsponse to ACcountable priority setting for Trust in health systems" is an EU-funded five-year intervention study started in 2006, which is testing the application and effects of the AFR approach in one district each in Kenya, Tanzania and Zambia. The objectives of REACT are to describe and evaluate district-level priority setting, to develop and implement improvement strategies guided by AFR and to measure their effect on quality, equity and trust indicators. Effects are monitored within selected disease and programme interventions and services and within human resources and health systems management. Qualitative and quantitative methods are being applied in an action research framework to examine the potential of AFR to support sustainable improvements to health systems performance. This paper reports on the project design and progress and argues that there is a high need for research into legitimate and fair priority setting to improve the knowledge base for achieving sustainable improvements in health outcomes.

BACKGROUND: Health, fair financing and responsiveness to the user's needs and expectations are seen as the essential objectives of health systems. Efforts have been made to conceptualise and measure responsiveness as a basis for evaluating the non-health aspects of health systems performance. This study assesses the applicability of the responsiveness tool developed by WHO when applied in the context of voluntary HIV counselling and testing services (VCT) at a district level in Kenya.

METHODS: A mixed method study was conducted employing a combination of quantitative and qualitative research methods concurrently. The questionnaire proposed by WHO was administered to 328 VCT users and 36 VCT counsellors (health providers). In addition to the questionnaire, qualitative interviews were carried out among a total of 300 participants. Observational field notes were also written.

RESULTS: A majority of the health providers and users indicated that the responsiveness elements were very important, e.g. confidentiality and autonomy were regarded by most users and health providers as very important and were also reported as being highly observed in the VCT room. However, the qualitative findings revealed other important aspects related to confidentiality, autonomy and other responsiveness elements that were not captured by the WHO tool. Striking examples were inappropriate location of the VCT centre, limited information provided, language problems, and concern about the quality of counselling.

CONCLUSION: The results indicate that the WHO developed responsiveness elements are relevant and important in measuring the performance of voluntary HIV counselling and testing. However, the tool needs substantial revision in order to capture other important dimensions or perspectives. The findings also confirm the importance of careful assessment and recognition of locally specific aspects when conducting comparative studies on responsiveness of HIV testing services.

There is a strong need for research capacity strengthening in developing countries. In this paper we present achievements and lessons learnt from a South-North collaboration. The collaboration is situated within the Kenyan-Danish Health Research Project (KEDAHR) which started in 1994 and lasted till 2004. A total of
41students (27 Kenyans and 14 Danish) undertaking studies at post-graduate and doctoral levels were involved over this period and more than 37 articles published in peer-reviewed journals and in edited books. In addition, there are other intangible benefits that have accrued over time.We conclude that the collaboration between the five institutions involved has been very productive. The focus on capacity development has led to a large pool of well trained anthropologists who are now forming a critical mass of expertise within which we expect future collaborations to be based.

Prompt and appropriate health seeking is critical in the management of childhood illnesses. This paper examines the health seeking behaviour in under-five child morbidity. It explores in detail actions taken by 28 mothers when their children become sick. Sixty-two in-depth interviews with mothers were conducted from four study communities. The mothers were identified from a demographic surveillance system. The interviews were tape-recorded, transcribed and thematically analysed. The study shows that mothers classify childhood illnesses into four main categories: (1) not serious—coughs, colds, diarrhoea; (2) serious but not life-threatening—malaria; (3) sudden and serious—pneumonia; and (4) chronic and therefore not requiring immediate action—malnutrition, tuberculosis, chronic coughs. This classification is reflected in the actions taken and time it takes to act. Shops are used as the first source of healthcare, and when the care moves out of the home, private health facilities are used more compared to public health facilities, while even fewer mothers consult traditional healers. Consequently we conclude that there is a need to train mothers to recognize potentially life-threatening conditions and to seek appropriate treatment promptly. Drug vendors should be involved in intervention programs because they reach many mothers at the critical time of health seeking.

This article assesses knowledge, attitudes, and practices regarding cervical cancer among rural women of Kenya. One hundred and sixty women (mean age 37.9 years) who sought various health care services at Tigoni subdistrict hospital, Limuru, Kenya, were interviewed using a semistructured questionnaire. In addition, three focus group discussions (25 participants) were held, five case narratives recorded, and a free list of cervical cancer risk factors obtained from a group of 41 women respondents. All women were aged between 20 and 50 years. About 40% knew cervical cancer, although many still lack factual information. A history of sexually transmitted diseases (61.5%), multiple sexual partners (51.2%), and contraceptive use (33%) were identified as risk factors. Other factors mentioned include smoking, abortion, and poor hygiene standards. High parity, early sexual debut, and pregnancy were not readily mentioned as risk factors. We propose a folk causal model to explain the link between these factors and cervical cancer. Lack of knowledge constrains utilization of screening services offered at the clinics. Consequently, respondents support educating women as a way to tackling issues on cervical cancer. It is recommended that an integrated reproductive health program that addresses comprehensively women's health concerns be put in place.

Institute of African Studies, University of Nairobi, Nairobi, Kenya. This article assesses knowledge, attitudes, and practices regarding cervical cancer among rural women of Kenya. One hundred and sixty women (mean age 37.9 years) who sought various health care services at Tigoni subdistrict hospital, Limuru, Kenya, were interviewed using a semistructured questionnaire. In addition, three focus group discussions (25 participants) were held, five case narratives recorded, and a free list of cervical cancer risk factors obtained from a group of 41 women respondents. All women were aged between 20 and 50 years. About 40% knew cervical cancer, although many still lack factual information. A history of sexually transmitted diseases (61.5%), multiple sexual partners (51.2%), and contraceptive use (33%) were identified as risk factors. Other factors mentioned include smoking, abortion, and poor hygiene standards. High parity, early sexual debut, and pregnancy were not readily mentioned as risk factors. We propose a folk causal model to explain the link between these factors and cervical cancer. Lack of knowledge constrains utilization of screening services offered at the clinics. Consequently, respondents support educating women as a way to tackling issues on cervical cancer. It is recommended that an integrated reproductive health program that addresses comprehensively women's health concerns be put in place.

Institute of African Studies, University of Nairobi, Nairobi, Kenya. This article assesses knowledge, attitudes, and practices regarding cervical cancer among rural women of Kenya. One hundred and sixty women (mean age 37.9 years) who sought various health care services at Tigoni subdistrict hospital, Limuru, Kenya, were interviewed using a semistructured questionnaire. In addition, three focus group discussions (25 participants) were held, five case narratives recorded, and a free list of cervical cancer risk factors obtained from a group of 41 women respondents. All women were aged between 20 and 50 years. About 40% knew cervical cancer, although many still lack factual information. A history of sexually transmitted diseases (61.5%), multiple sexual partners (51.2%), and contraceptive use (33%) were identified as risk factors. Other factors mentioned include smoking, abortion, and poor hygiene standards. High parity, early sexual debut, and pregnancy were not readily mentioned as risk factors. We propose a folk causal model to explain the link between these factors and cervical cancer. Lack of knowledge constrains utilization of screening services offered at the clinics. Consequently, respondents support educating women as a way to tackling issues on cervical cancer. It is recommended that an integrated reproductive health program that addresses comprehensively women's health concerns be put in place.

The author illustrates how qualitative data from open-ended interviews, pile sorts, and triad sorts can be used to test quantitatively for intracultural variation in norms. Specifically, the author tests whether Gusii men and women in the Suneka Division of Kisii District in southwest Kenya have developed a common set of standards in response to symptoms of malaria. In this small sample, the focus is on internal, rather than external, validity. While the findings about Gusii responses to malaria are not generalizable beyond the village where the data were collected, the method described may be used to study cultural similarities across socioeconomic, gender, and other groups.

The author illustrates how qualitative data from open-ended interviews, pile sorts, and triad sorts can be used to test quantitatively for intracultural variation in norms. Specifically, the author tests whether Gusii men and women in the Suneka Division of Kisii District in southwest Kenya have developed a common set of standards in response to symptoms of malaria. In this small sample, the focus is on internal, rather than external, validity. While the findings about Gusii responses to malaria are not generalizable beyond the village where the data were collected, the method described may be used to study cultural similarities across socioeconomic, gender, and other groups.

The author illustrates how qualitative data from open-ended interviews, pile sorts, and triad sorts can be used to test quantitatively for intracultural variation in norms. Specifically, the author tests whether Gusii men and women in the Suneka Division of Kisii District in southwest Kenya have developed a common set of standards in response to symptoms of malaria. In this small sample, the focus is on internal, rather than external, validity. While the findings about Gusii responses to malaria are not generalizable beyond the village where the data were collected, the method described may be used to study cultural similarities across socioeconomic, gender, and other groups.

The author illustrates how qualitative data from open-ended interviews, pile sorts, and triad sorts can be used to test quantitatively for intracultural variation in norms. Specifically, the author tests whether Gusii men and women in the Suneka Division of Kisii District in southwest Kenya have developed a common set of standards in response to symptoms of malaria. In this small sample, the focus is on internal, rather than external, validity. While the findings about Gusii responses to malaria are not generalizable beyond the village where the data were collected, the method described may be used to study cultural similarities across socioeconomic, gender, and other groups.

The author illustrates how qualitative data from open-ended interviews, pile sorts, and triad sorts can be used to test quantitatively for intracultural variation in norms. Specifically, the author tests whether Gusii men and women in the Suneka Division of Kisii District in southwest Kenya have developed a common set of standards in response to symptoms of malaria. In this small sample, the focus is on internal, rather than external, validity. While the findings about Gusii responses to malaria are not generalizable beyond the village where the data were collected, the method described may be used to study cultural similarities across socioeconomic, gender, and other groups.

The author illustrates how qualitative data from open-ended interviews, pile sorts, and triad sorts can be used to test quantitatively for intracultural variation in norms. Specifically, the author tests whether Gusii men and women in the Suneka Division of Kisii District in southwest Kenya have developed a common set of standards in response to symptoms of malaria. In this small sample, the focus is on internal, rather than external, validity. While the findings about Gusii responses to malaria are not generalizable beyond the village where the data were collected, the method described may be used to study cultural similarities across socioeconomic, gender, and other groups.

The author illustrates how qualitative data from open-ended interviews, pile sorts, and triad sorts can be used to test quantitatively for intracultural variation in norms. Specifically, the author tests whether Gusii men and women in the Suneka Division of Kisii District in southwest Kenya have developed a common set of standards in response to symptoms of malaria. In this small sample, the focus is on internal, rather than external, validity. While the findings about Gusii responses to malaria are not generalizable beyond the village where the data were collected, the method described may be used to study cultural similarities across socioeconomic, gender, and other groups.

The author illustrates how qualitative data from open-ended interviews, pile sorts, and triad sorts can be used to test quantitatively for intracultural variation in norms. Specifically, the author tests whether Gusii men and women in the Suneka Division of Kisii District in southwest Kenya have developed a common set of standards in response to symptoms of malaria. In this small sample, the focus is on internal, rather than external, validity. While the findings about Gusii responses to malaria are not generalizable beyond the village where the data were collected, the method described may be used to study cultural similarities across socioeconomic, gender, and other groups.

The author illustrates how qualitative data from open-ended interviews, pile sorts, and triad sorts can be used to test quantitatively for intracultural variation in norms. Specifically, the author tests whether Gusii men and women in the Suneka Division of Kisii District in southwest Kenya have developed a common set of standards in response to symptoms of malaria. In this small sample, the focus is on internal, rather than external, validity. While the findings about Gusii responses to malaria are not generalizable beyond the village where the data were collected, the method described may be used to study cultural similarities across socioeconomic, gender, and other groups.

The author illustrates how qualitative data from open-ended interviews, pile sorts, and triad sorts can be used to test quantitatively for intracultural variation in norms. Specifically, the author tests whether Gusii men and women in the Suneka Division of Kisii District in southwest Kenya have developed a common set of standards in response to symptoms of malaria. In this small sample, the focus is on internal, rather than external, validity. While the findings about Gusii responses to malaria are not generalizable beyond the village where the data were collected, the method described may be used to study cultural similarities across socioeconomic, gender, and other groups.

The author illustrates how qualitative data from open-ended interviews, pile sorts, and triad sorts can be used to test quantitatively for intracultural variation in norms. Specifically, the author tests whether Gusii men and women in the Suneka Division of Kisii District in southwest Kenya have developed a common set of standards in response to symptoms of malaria. In this small sample, the focus is on internal, rather than external, validity. While the findings about Gusii responses to malaria are not generalizable beyond the village where the data were collected, the method described may be used to study cultural similarities across socioeconomic, gender, and other groups.

The author illustrates how qualitative data from open-ended interviews, pile sorts, and triad sorts can be used to test quantitatively for intracultural variation in norms. Specifically, the author tests whether Gusii men and women in the Suneka Division of Kisii District in southwest Kenya have developed a common set of standards in response to symptoms of malaria. In this small sample, the focus is on internal, rather than external, validity. While the findings about Gusii responses to malaria are not generalizable beyond the village where the data were collected, the method described may be used to study cultural similarities across socioeconomic, gender, and other groups.

The author illustrates how qualitative data from open-ended interviews, pile sorts, and triad sorts can be used to test quantitatively for intracultural variation in norms. Specifically, the author tests whether Gusii men and women in the Suneka Division of Kisii District in southwest Kenya have developed a common set of standards in response to symptoms of malaria. In this small sample, the focus is on internal, rather than external, validity. While the findings about Gusii responses to malaria are not generalizable beyond the village where the data were collected, the method described may be used to study cultural similarities across socioeconomic, gender, and other groups.

The author illustrates how qualitative data from open-ended interviews, pile sorts, and triad sorts can be used to test quantitatively for intracultural variation in norms. Specifically, the author tests whether Gusii men and women in the Suneka Division of Kisii District in southwest Kenya have developed a common set of standards in response to symptoms of malaria. In this small sample, the focus is on internal, rather than external, validity. While the findings about Gusii responses to malaria are not generalizable beyond the village where the data were collected, the method described may be used to study cultural similarities across socioeconomic, gender, and other groups.